Introduction to ECGs. R. Gentry Wilkerson, MD Asst. Professor Department of Emergency Medicine
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1 Introduction to ECGs R. Gentry Wilkerson, MD Asst. Professor Department of Emergency Medicine
2 Objectives Lead Placement Hexaxial System ECG Paper Systematic Approach to Reading an ECG
3 Lead Placement
4 Hexaxial System Limb Leads (Bipolar): RA, LA, RL, LL Forms Einthoven s Triangle I : 0º II : 60º III : 120º
5 Hexaxial System Augmented Leads (Unipolar) Utilize a central negative terminal avl : -30º avf : 90º avr : -120º
6 Hexaxial System
7 Precordial Leads
8 ECG Paper Height = millivolts Width = Time 1 mm x 1 mm
9
10 Calibration Vertical Axis y 1 Small Square = 1 mm (0.1 mv) 1 Large Square = 5 mm (0.5 mv) 2 Large Squares = 10 mm (1 mv) Horizontal Axis x 1 Small Square = 0.04 sec 1 Large Square = 0.2 sec 5 Large Squares = 1 sec
11 HIGH LATERAL SEPTAL ANTERIOR I V1 V4 II avl V2 V5 LATERAL III avf V3 V6 INFERIOR RHYTHM STRIP
12 ECG Complex
13 Interpreting the ECG Rate Rhythm - Ectopic beats? Axis Intervals - Blocks? Atrial Abnormalities Ventricular hypertrophy ST/T changes
14 The Rate 5 big boxes = 1 sec big boxes = 60 sec Rate = 300/# big boxes
15 The Rate Multiply # beats on rhythm strip x 5
16 The Rhythm Is it fast or slow? Is it regular or irregular? Are there p waves present? Are all p waves the same? Does each QRS have a p wave? Is the PR interval constant?
17 The Rhythm Are the p waves and QRS complexes associated with each other? Are the QRS complexes narrow or wide? Are the QRS complexes grouped or not? Are there dropped beats?
18 The Rhythm Supraventricular Rhythms
19 Normal Sinus Rhythm Rate: bpm Regular P wave present P:QRS ratio: 1:1 PR Interval: Normal QRS width: Normal Grouping: None Dropped: None
20 Sinus Bradycardia Rate: Less than 60 Regular P wave present P:QRS ratio: 1:1 PR Interval: Normal QRS width: Normal Grouping: None Dropped: None
21 Sinus Tachycardia Rate: Greater than 100 Regular P wave present P:QRS ratio: 1:1 PR Interval: Normal QRS width: Normal Grouping: None Dropped: None
22 Sinus Arrhythmia Rate: Varies with respiration P wave present P:QRS ratio: 1:1 PR Interval: Normal QRS width: Normal Grouping: None Dropped: None
23 Sinus Pause / Arrest Rate: Varies Irregular P wave present P:QRS ratio: 1:1 PR Interval: Normal QRS width: Normal Grouping: None Dropped: None
24 Sinoatrial Block Rate: Varies Irregular P present except in areas of dropped beat P:QRS ratio: 1:1 PR Interval: Normal QRS width: Normal Grouping: None Dropped: Yes
25 Ectopic Atrial Tachycardia Rate: Greater than 100 Regular P wave present P:QRS ratio: 1:1 PR Interval: Normal QRS width: Normal Grouping: None Dropped: None
26 Ectopic Atrial Tachycardia
27 Wandering Atrial Pacemaker Rate: Less than 100 Irregularly irregular P wave 3 morphologies P:QRS ratio: 1:1 PR Interval: Varies QRS width: Normal Grouping: None Dropped: None
28 Multifocal Atrial Tachycardia Rate: Greater than 100 Irregularly irregular P wave 3 morphologies P:QRS ratio: 1:1 PR Interval: Varies QRS width: Normal Grouping: None Dropped: None
29 Atrial Flutter Rate: atrial , ventricular Usually regular P wave- flutter waves P:QRS ratio: Often 2:1 PR Interval: Variable QRS width: Normal Grouping: None Dropped: None
30 Atrial Fibrillation Rate: Variable Irregularly irregular P waves chaotic P:QRS ratio: None PR Interval: None QRS width: Normal Grouping: None Dropped: None
31 Rate: Regular P waves- none, antegrade, retrograde P:QRS ratio: None or 1:1
32 Junctional Rhythm PR Interval: None, short or negative QRS width: Normal Grouping: None Dropped: None
33 Accelerated Junctional Rhythm Rate: bpm Regular P waves- none, ante-, retrograde P:QRS ratio: none or 1:1 PR Interval: None, short or neg QRS width: Normal Grouping: None Dropped: None
34 The Rhythm Ventricular Rhythms
35 Idioventricular Rhythm Rate: bpm Regular P wave absent P:QRS ratio: None PR Interval: None QRS width: Wide, bizarre Grouping: None Dropped: None
36 Accel. Idioventricular Rhythm Rate: bpm Regular P wave absent P:QRS ratio: None PR Interval: None QRS width: Wide, bizarre Grouping: None Dropped: None
37 Ventricular Tachycardia Rate: bpm Regular P wave?buried P:QRS ratio: None PR Interval: None QRS width: Wide, bizarre Grouping: None Dropped: None
38 Ventricular Tachycardia Fusion Beats Mix between V-tach and sinus morphologies Capture Beats Sinus morphology
39 Ventricular Tachycardia Josephson s Sign Small notching near the low point of S wave Brugada s Sign Interval from R wave to bottom of S wave is 0.10 seconds
40 Torsades de Pointes Rate: bpm Irregular P wave: None P:QRS ratio: None PR Interval: None QRS width: Variable Grouping: N/A Dropped: None
41 Ventricular Fibrillation Rate: Indeterminate Irregular P wave: None P:QRS ratio: None PR Interval: None QRS width: None Grouping: None Dropped: No beats
42 Axis
43 Axis
44 Axis The axis is the direction of the sum vector of ventricular depolarization
45 Axis
46 Axis
47 Axis
48 Axis
49 Intervals
50 PR Interval Normal: 0.12 to 0.20 sec Short PR interval Wolff-Parkinson-White Lown-Ganong-Levine AV Junctional Rhythm (see arrhythmia lecture)
51 Wolff-Parkinson-White Defined by: Short PR (<0.12 sec) with normal P wave May be normal in 12% Wide QRS complex ( 0.11 sec) Presence of a delta wave ST-T wave changes Association with paroxysmal tachycardias
52 PR Interval Normal: 0.12 to 0.20 sec Long PR interval 1 st Degree AV Block AV nodal disease Enhanced vagal tone Myocarditis Myocardial infarction (especially inferior MIs) Electrolyte imbalance Drugs (Beta Blockers, CCBs, cardiac glycosides)
53 QRS Duration Normal : 0.06 to 0.10 sec Hyperkalemia Ventricular tachycardia Idioventricular rhythms Drug effects and overdoses Wolff-Parkinson-White BBBs and Intraventricular conduction delay PVCs Aberrantly conducted complexes
54 QT Interval Must be corrected for rate = QT c Bazett s Formula Fridericia s Formula Hodge s Formula Normal is < 440 QTC = QT (HR 60) 3
55 QT C Causes of shortened QT c Hypercalcemia Digitalis Tachycardia
56 QT C Causes of prolonged QT c Hypocalcemia Drugs (Quinidine, Procainamide, Psychotropics, Tricyclics, Pentamidine) CNS Hypothermia Hypothyroidism Ischemic Heart Disease Genetic (Long QT Syndrome)
57 Torsades de Pointes Increased risk when QTc > 500 msec
58 Heart Blocks
59 Atrioventricular (AV) Block Conduction between the atria and ventricles is altered Abnormality can be located anywhere in the AV node, His bundle, or bundle branches May result in either a partial or complete block
60 1st Degree AV Block Every atrial impulse conducts to the ventricles and a regular ventricular rate is produced PR interval exceeds 0.20 sec (5 boxes) in adults Almost always asymptomatic Etiology Medications Age Increased vagal tone
61 1st Degree AV Block
62 2nd Degree AV Block (Mobitz I- Wenckebach) Progressive prolongation of AV conduction (and the P R interval) until an atrial impulse is completely blocked Conduction ratios are used to indicate the ratio of atrial to ventricular depolarizations 3:2 indicates that two of three atrial impulses are conducted into the ventricles
63 2nd Degree AV Block (Mobitz I- Wenckebach)
64 2nd Degree AV Block (Mobitz II) P R interval remains constant before and after the non-conducted atrial beats Usually occur in the infranodal conducting system Often have co-existing fascicular or BB blocks Often due to permanent structural defects in the infranodal conducting system May progress suddenly to complete heart block
65 2nd Degree AV Block (Mobitz II) RR interval surrounding the dropped beat(s) is an exact multiple of the preceding RR interval If there is 2:1 conduction, one cannot differentiate between Mobitz I and II
66 3rd Degree AV Block (Complete Heart Block) Complete absence of AV conduction Perfusing rhythm is maintained by a junctional or ventricular escape rhythm Regular P-P intervals, R-R intervals Variable P-R intervals
67 AV Dissociation Term indicates only the occurrence of independent atrial and ventricular contractions Passive Type- default or "escape" like in thirddegree AV block Active Type- when the ventricular rhythm usurps control May be caused by entities other than complete heart block Accelerated Idioventricular Rhythm Ventricular Tachycardia
68 Right Bundle Branch Block
69 Right Bundle Branch Block Major Criteria QRS 0.12 sec Slurred S wave in leads I and V6 RSR pattern in V1 May get a QR pattern if there is previous anteroseptal infarct
70 Right Bundle Branch Block
71 Right Bundle Branch Block
72 Left Bundle Branch Block Major Criteria QRS 0.12 sec Broad, monomorphic R waves in I and V6 with no Q waves Broad, monomorphic S waves in V1 May have a small r wave
73 Left Bundle Branch Block
74 Left Bundle Branch Block
75 Left Bundle Branch Block
76 Left Ventricular Hypertrophy
77 Left Ventricular Hypertrophy Compare these two 12-lead ECGs. What stands out as different with the second one?
78 Left Ventricular Hypertrophy As the heart muscle wall thickens there is an increase in electrical forces moving through the myocardium resulting in increased QRS voltage
79 Criteria for LVH Gubner-Ungerleider 1943 R I > 15 R I + S III > 25 Sokolow-Lyon 1949 S V1 + R (V5 or V6) > 35 R avl > 11 Siegel 1982 Total 12-Lead voltage > 175 Murphy 1984 S (V1 or V2) + R (V5 or V6) > 35 Cornell (Casale) 1985 S V3 + R avl > 28 ( ) 20 ( )
80 Right Ventricular Hypertrophy
81 Right Ventricular Hypertrophy Right Axis Deviation R > S in V1 Deep S in left precordial leads Slight prolongation of QRS up to 120 msec Strain pattern in V1-3 May have right atrial abnormality
82 Causes of R > S in V1 Right Ventricular Hypertrophy True Posterior MI Lead Misplacement RBBB WPW Type A Normal variant
83 Q Waves Significant if: More than 1/3 height of QRS Wider than 0.03 sec Septal Qs (normal variant) Result of initial depolarization occurring in the septum from left to right Often found in left sided leads: I, av L and V6
84 Q Waves
85 ST Segment
86 ST Segment Elevation ST elevation > 1 mm in limb leads and > 2 mm in chest leads indicates an evolving acute MI until proven otherwise. Other primary causes: Early repolarization (normal variant) Pericarditis Ventricular aneurysm Pulmonary embolism
87 STEMI Localization
88 ST Segment Depression Primary Causes Myocardial Ischemia LVH Intraventricular conduction defects Medication (digitalis) Reciprocal changes in leads opposite area of acute MI
89 Sgarbossa Criteria For detecting an AMI in the setting of LBBB Derived from the GUSTO-1 trial Not perfect in screening for AMI. Use as another data point for risk-stratifying. Sgarbossa criteria hold true for LBBB pattern seen in pacemaker patients
90 Sgarbossa Criteria
91 Pericarditis
92 Pericarditis Stage I First few days 2 weeks ST elevation, PR depression Up to 50% of pt with symptoms / rub do NOT have or evolve into stage I
93 Pericarditis Stage I
94 Pericarditis Stage II Stage II Lasts days weeks Normalization of ST and PR segments ST returns to baseline, flat T waves
95 Pericarditis Stage II
96 Pericarditis Stage III Stage III Begins after 2-3 weeks, lasts several weeks Widespread T wave inversion
97 Pericarditis Stage III
98 Pericarditis Stage IV Stage IV Lasts up to several months Gradual resolution of T wave changes
99 Osborn Waves Positive deflections occurring at the junction between the QRS complex and the ST segment, the J point, has a myocardial infarction-like elevation Associated with hypothermia
100 Osborn Waves
101 Last night...
102 Questions?
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